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October 19, 2010

Medicare Hospital Comparison Website May Not Help Patients Locate Best Places For High-Risk Surgery

by Sam Savage

Information available on a government Web site designed to help patients choose high-quality hospitals does not appear to help Medicare beneficiaries identify facilities with better outcomes for high-risk surgeries, according to a report in the October issue of Archives of Surgery, one of the JAMA/Archives journals.

In an effort to reduce variations in surgical quality, the Centers for Medicare and Medicaid Services (CMS) now requires hospitals to report data from the national Surgical Care Improvement Project involving measures taken to prevent infection and blood clots, according to the background information in the article. "Hospitals are required to submit data quarterly, which are posted on the Hospital Compare Web site (http:www.hospitalcompare.hhs.gov), to receive annual Medicare payment updates," the authors write. "This reporting is believed to aid patients and payers in choosing high-quality hospitals and to stimulate quality improvement among reporting hospitals. It is unclear whether these efforts will translate into better outcomes for surgical patients."

Lauren H. Nicholas, Ph.D., and colleagues at the University of Michigan and Michigan Surgical Collaborative for Outcomes Research and Evaluation, Ann Arbor, analyzed Medicare inpatient claims data for 325,052 patients undergoing one of six high-risk surgical procedures at 2,189 hospitals in 2005 or 2006. They used Hospital Compare data to calculate a score for each facility based on the number of times a hospital complied with recommended measures for each eligible patient per year.

These compliance scores ranged widely, from 53.7 percent in low-compliance hospitals to 91.4 percent in high-compliance hospitals. "We found little evidence of a consistent relationship between hospital compliance with processes of care and operative mortality rate," the authors write. "In univariate analysis, mortality rates in the lowest compliance hospitals were statistically indistinguishable from those in the highest quintile of compliance for all procedures studied except aortic valve replacement, in which the highest compliance hospitals had lower mortality rates."

Compliance scores accounted for only 3.3 percent of the variance in hospitals' death rates. In addition, the 95,387 facilities that did not report data at all had similar rates of death to the one-fifth of hospitals with the highest compliance scores. Scores were also not associated with outcomes when each of the six procedures"”abdominal aortic aneurysm repair, aortic valve repair, coronary artery bypass graft, esophageal resection, mitral valve repair or pancreatic resection"”were considered individually.

Several potential explanations exist for the lack of association, the authors note. "The Surgical Care Improvement Project measures are low-leverage because they relate to secondary and relatively less important outcomes," they write. "Even when processes are tied to an important outcomes such as pulmonary embolism [a blood clot that has traveled to the lungs], these events are rare and offer insufficient variation to differentiate between high- and low-quality hospitals."

"Despite the intentions of the CMS to provide patients with information that will facilitate patient choice of high-quality hospitals, currently available information on the Hospital Compare Web site will not help patients identify hospitals with better outcomes for high-risk surgery," they conclude. "The CMS needs to identify higher leverage process measures and devote greater attention to profiling hospitals based on outcomes for improved public reporting and pay-for-performance programs. Future research should ascertain whether process measures become more useful as indicators of surgical quality as public reporting programs mature."